A sample 1500 claim form [PDF] is available on the Centers for Medicare & Medicaid Services (CMS) website. CMS also has a sample claim form filled out for PQRS in Appendix D of its 2015 PQRS Implementation Guide.
- ICD-9/10 codes are placed in box 21
- CPT codes are placed in box 24D
- G-codes are placed in box 24D following the CPT codes of the procedures performed